Trauma Care 2017 conference

The Trauma Care 2017 conference (@TraumaCareUK) was held at Staffordshire’s Yarnfield Park 15-18 March.

In total, there were over 26 conference streams and an incredible 200 speakers! Hundreds, if not thousands, of delegates included pre-hospital and in-hospital clinicians, fire and rescue personnel, military, and police officers plus an enormous number of volunteers who represented groups such as community first responder and search and rescue organisations from across the UK.

Yarnfield Park (@YarnfieldPark1) itself developed from housing used by temporary workers at a nearby world war two munitions factory. Today, the site is a cross between a small university campus, a Travelodge and an outdoor activity centre.

I arrived at 3pm on the third day (17 March). Checking into the accommodation was easy, and I found myself in a small but modern room in the Derwent block. Free WiFi, available across the site, was excellent and it was simple to find my way around the conference centre.

I caught Karim Brohi’s (@KarimBrohi) keynote presentation about trauma induced coagulopathy; particularly interesting points included the realisation many blood products used in emergency medicine are optimised and packaged for the longest possible shelf life, rather than ideal contents and volumes for trauma management. Perhaps there’s a future for special blood banks with tailor made solutions to these issues.

The evening meal was in a modern canteen setting; the £5.99 meal was fairly simple chicken and roast vegetables. The bar was fairly quiet and served until 11.30pm, giving time for plenty of chatter between delegates, Trauma Care faculty and some of the commercial exhibitors. I made it to bed around 1am. At first the bed felt quite firm, but I slept through the night and woke up refreshed the next morning.

The fried breakfast was very good value, which set me up for the day. I was speaking at the Student Paramedic conference so went to the room and got ready. Around 60 student paramedics from across England attended, and the day was organised and facilitated by Andy Thomas (@AndyThomas135).

The first speaker was Paul Gowens (@SASConsultPara), Lead Consultant Paramedic with the Scottish Ambulance Service, who spoke about management of traumatic cardiac arrest. Paul impressed how important it is for a lone responder to consider straightening grossly deformed legs, applying a pelvic splint, obtaining vascular access and give fluids, decompressing the chest and securing the airway before commencing chest compressions. Where two clinicians are available, these should happen simultaneously.

7.5% of patients do survive a traumatic cardiac arrest, which compares favourably to medical arrests, so it’s worthwhile attempting resuscitation in this group.

My session followed. I spoke about changes in paramedic trauma care 2006-present, and speculating what paramedic trauma care might look like in 2026. I got some great feedback from Twitter and feel genuinely humbled by some of the compliments I received.

Richard Steyn, cardiothoracic surgeon, led a talk on chest injuries, explaining different factors can be associated with the pathology of pneumothorax and reminding the audience bilateral crushing forces can produce flail chest injures which affect the entire ribcage but also be difficult to easily identify.

I next toured the 20-30 exhibitor stands; the British Army were showcasing opportunities for health professionals, TraumaFX (@TraumaFXUK) demonstrated their lifelike mannequins and explained just how durable they are whilst amenable to intense training scenarios, and even a dog first aid instructor was explaining how to care for animals used in search and rescue!

Martin Berry (@MartinBerryUK) spoke about the College of Paramedics’ (@ParamedicsUK) post-graduate framework, and potential opportunities for specialised, advanced and consultant paramedics both in terms of trauma and the wider profession. There were some really exciting ideas and a welcome reminder that supporting the College of Paramedics is the most effective way to support our professional development and secure a bright future.

Officers from Durham and Cleveland police (@TTCUrlayNook) spoke about firearms units responding to a Marauding Terrorist Firearms Attack (MFTA) and reviewed the trauma interventions which can be offered by skilled police officers at the scene of deliberate violence, but also at road traffic accidents in support of the ambulance service.

The closing session was hosted by Andy Thomas, and I, Martin Berry and Paul Elliott (@PaulElliott_) fielded a range of questions about management of hypothermia, whether the HCPC, or another body, should maintain a register of paramedics in advanced roles and what the future holds for paramedic education.

Just before 5pm, the conference closed and delegates made their way home, taking new knowledge and experience back to their daily practice and training. With such high quality teaching underpinning the entire event, it’s certain that injured patients will have already benefitted from Trauma Care 2017.

Matt Green @MLG1611
March 2017

Vehicle not required?

I really enjoy leaving patients at home. There is an enormous professional satisfaction in responding to a 999 call, providing a thorough assessment and formulating a good discharge plan to leave the patient in the comfort of their own home with appropriate arrangements.

As long as home is safe, the patient avoids the disruption of a hospital visit; they don’t become a burden on a busy Emergency Department and they are left with a good impression of ambulance practitioner’s clinical aptitude.

My `record` for avoiding transport to the Emergency Department was leaving 9 patients out of 10 at home in a single shift. However, recently I have been getting nowhere near this rate and I think it’s linked to the increased effectiveness of telephone services such as 111 and ambulance trusts’ clinical triage facilities. This is fantastic news as patients are getting what they need and ambulance resources are being conserved for more appropriate situations. However, it leaves me wondering whether Double Manned Ambulances leaving patients at home has had its heyday and whether conveyance rates of patients actually seen by ambulance crews will increase.

Will there ever come a day when telephone-based assessment, advice and referral will be so effective it will become exceptionally rare for ambulance crews to leave patients at home since the unavoidable need for conveyance has been correctly identified over the phone?

Matt Green @MLG1611
June 2016

Video: How well do over-the-counter painkillers work?

Poster: How effective are common painkillers?

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Weekly Twitter #MedChat, 8-9pm UK Time, Thursdays

DIY IV simulator

Paramedic Prescribing

Imagine a paramedic prescriber working in a 'traditional' ambulance role (double crewed ambulance or response vehicle, in an appropriately designated Advanced or Consultant Paramedic role with all the required governance and support). Perhaps their background specialism is either critical or urgent care, but as an ambulance resource today they can be sent to anything control see fit.

Their first job is to a patient with a urinary tract infection with pain and nausea. They are allergic to trimethoprim. The patient is assessed and prescribed an antibiotic, pain relief and an anti-emetic and successfully discharged at home with at least the same quality of care as would have been afforded by a competent GP.

The next incident is to a child with prolonged seizures which has caused a hypoxic cardiac arrest. They have been resuscitated but remain very unstable. They are maybe going to benefit from sedation, ventilation and inotropic support as well as second-line anti-seizure medication. Their blood sugar is 29.2 and they are showing signs of diabetic ketoacidosis.

Is the onus on the individual paramedic prescriber/trust/wider profession to provide medication intervention to at least the same level as a competent paediatric intensivist?

Other non-medical prescribers work in more predictable surroundings such as urgent care centres, intensive care or community specialist teams. If they are in an acute hospital they are in easy reach of other prescribers who can support decision making. HEMS doctors predict they are going to be targeted at critical care and out of hours GPs urgent care. When something crosses this boundary, other prescribers might reasonably argue 'I wasn't expecting to encounter this situation so was not competent or appropriately equipped to deal with it'.

In an ambulance service where calls are not predictable and clinicians get whatever job needs to be covered, are paramedic prescribers going to be in a unique and untested position of being expected to prescribe to all and be carrying a formulary to support that? Or will it he medico-legally safe to argue they provide competent prescribing skills to some patients but not others?

Matt Green @MLG1611
February 2017

My hopes and expectations for the ambulance service as a member of Generation Y

What are my expectations and demands from my service:

·         All healthcare practitioners are expected to be professional gamblers (taking a gamble that pleuritic chest pain is not cardiac in origin and acting on it after examination, for example). Ambulance staff take some really big gambles and it’s exceptionally rare to get it wrong. I expect my service to value the gambles that pay off because it’s good for the patient, practitioner and health economy but also embrace the learning points when they don’t without unbridled retribution.

·         Real clinical leadership from career ambulance staff/paramedics without intentionally damaging manipulation from other professions and staff groups.

·         Recognition that `paramedic` is not the same as `ambulance person` anymore. Paramedics are very highly valued commodities away from the traditional ambulance services. If services don’t value and embrace their staff, they can easily leave for something more lucrative. This will only increase when paramedic prescribing becomes a reality and non-ambulance services see paramedics as ways to solve many other healthcare shortages. There is a risk that answering traditional emergency calls is the least `good` place for a paramedic to work and practitioner quality will drop.

What do I like:

·         I was 19 when I first worked on an ambulance. I had responsibility, authority, represented a great organisation and became hugely motivated for a role I adored plus confidence in the 4 year degree I was taking leading to a paramedic registration. I don’t think I could have had all this at 19 in any other job, except perhaps in the military.

·         I do get an adrenaline rush just as each incident comes in, hoping for something challenging and exciting. People do the job and stick with it for that occasional adrenaline rush.

·         I like medical critical care and problem solving in urgent care. I am less excited by trauma care. I like mentoring, I like leading and I get a thrill forcing entry to property where legally and clinically justified.

·         “Hello, my name is Matt. I am a paramedic” is a great statement to say to people, professionally and socially. The public really value and take confidence from what they feel that means, which is nice for my ego! Being a paramedic has opened good and fairly paid job opportunities away from ambulance services too.

What don’t I like:

·         Not having every tool I need pre-hospitally; my contracted job is to see the sickest, most injured babies, adults and children and to deal with them for up to 2 hours before reaching an appropriate hospital. In critical care, if a few milligrams of morphine, some saline or an non-drug assisted airway don’t work I don’t really have any technical skills left to offer and that means patient suffering and deterioration. In urgent care, I can’t leave patients with a supply of painkillers, comprehensively close a wound or directly book follow-up appointments meaning more taken to the emergency department or becoming an excess burden on alternative care pathways, which is bad for the health economy overall.

·         I have worked in environments which do have a racism problem, are clinically neglectful and felt corrupt. The rhetoric is that this is unacceptable but people do seemingly get away with it as there is little appetite to cast light on it.

·         The Health and Care Professions Council themselves recognise that going the extra mile for patients is a risk factor for triggering fitness to practise proceedings. The best ambulance staff  go the extra mile and shouldn’t need to feel at-risk about it. 

·         Investment in bespoke technology; Apple, Samsung and other manufacturers have already solved many of the technology issues associated with digital communications, electronic patient reports and access to clinical information yet ambulance services invest heavily in special designs that are always going to be niche and underperform.

·         Late finishes and commuting to work during rush hour are incredibly degrading on mental health. I don’t know how ambulance services solve these issues but there needs to be something.

·         “I just take everyone to hospital and let them treat them if they want to” is still a viable career plan and equally rewarded than those practitioners who give gold standard care, arrange alternative care pathways and become clinical leaders.

·         Feeling like I am playing `second fiddle` to doctors who are part of volunteer and charitable schemes, and therefor inconsistent and can be professionally domineering. Paramedics should be the pre-hospital clinical leaders and should be fully supported to provide gold standard care as part of the statutory response, not the nice-to-have voluntary response.

·         Guideline developments which feel outdated when they are released, don’t reflect current gold standards or were written assuming you’re always just a few short minutes from the emergency department, which is not where clinical practise currently is.

What do I miss:

·         I celebrated my 20^th birthday alone, mopping an ambulance in a car park. The significance of the loneliness hit me and I wondered if I missed out on having a more traditional 20^thbirthday.

·         I miss colleagues who left, or were pushed out, because their face didn’t fit. There’s a lot of them. During my career, the suicide rate has been substantial and it’s not clear why.

What do I wish for:

·         The biggest cause of loss of talented staff is late finishes and lack of serious career progression. I wish there was investment in these issues rather than endless pushes for new staff who burn out quickly.

·         I wish for the College of Paramedics to become stronger; it’s the best hope of achieving so much for UK ambulance staff.

·         Summing up the costs of my undergraduate degree, postgraduate degree course and continuing professional development activities, I have personally invested somewhere between £40,000-45,000 in my ambulance career and will be in student debt until I am almost 50 years old. The ambulance services are incredibly lucky to have so many staff prepared to take this level of financial risk; for me it means I can’t afford to buy a house. I can’t really afford to think about having a family. There is a real risk I won’t be able to provide for my future. Currently, there is no clear career ladder and it’s hard to objectively justify whether it’s all worth it.

·         I wish to work hard and get to my late 30s, 40s, 50s and 60s in a reasonably senior clinically facing job which feels stable, safe and worthwhile which understands I want to work hard but just can’t do as much as I could at age 22.

Matt Green @MLG1611

December 2015

New lease of life for ROSC

The United Kingdom’s ambulance services are successfully restoring a pulse in more cardiac arrest victims than ever before1,2 and it’s a huge cause for celebration3. The root cause appears to be improvements in the quality of cardiopulmonary resuscitation using non-technical skills such as  pit-crew resuscitation tactics4 and increasingly appropriate use of advanced techniques including airway management and clinically effective doses of evidence-based drugs. Studies are collecting currently data about some of these technical issues to enhance the literature5,6. 

Today, it is argued that most patients are receiving similarly skilled resuscitation inside and outside of the hospital environment and that’s a great credit to a paramedic profession barely two decades old7. 

Moreover, patients who are successfully resuscitated are going on to benefit from extremely effective alternative care pathways which bypass traditional delays associated with emergency department admission to reach definitive care sooner. Patients with acute myocardial infarction may directly access primary percutaneous coronary intervention (PPCI), for example8. 

2013’s Joint Royal College Ambulance Liaison Committee (JRCALC) Clinical Practice Guidelines9 for return of spontaneous circulation (ROSC) encourage clinicians to: 

*assess the victim using an Airway, Breathing, Circulation, Disability and Expose/Examine approach
* Provide controlled oxygenation and ventilation
* Acquire a 12-lead electrocardiogram
* Undertake investigations
* Treat the precipitating cause
* Provide temperature control
* Provide therapeutic hypothermia only with appropriate equipment

Whilst patients displaying ROSC in a hospital setting have traditionally benefitted from sedation and inotropes where indicated10, this has been outside of the traditional scope of practice for ambulance staff in the United Kingdom. It is uncertain whether this paucity of skills has precipitated further cardiac arrests and resulted in poorer outcomes in the recently resuscitated population.

Things are set to change as a result of the 2015 Resuscitation Council (UK) (RCUK) Prehospital resuscitation guidelines11, which have more detailed and specific advice on pre-hospital return of spontaneous circulation.

Key recommendations:

* Continuous capnography
* Saline boluses in the hypotensive patient
* Cardioversion of pulsed ventricular tachycardia causing instability
* Intravenous adrenaline boluses for profound hypotension, titrated to effect (in the context of governance where telephone medical support is available)
* Transport to a primary percutaneous coronary intervention-capable hospital, regardless of consciousness level, where ST segment elevation is detected
* Mechanical ventilation targeted to normal oxygen saturations and capnography values
* Intravenous diazepam or midazolam for those cerebrally irritated or combative (with appropriate telephone medical support if advanced medical care is not available on scene)
* Transporting the patient supine with their head at a 300 tilt

It is yet to be seen how closely the latest edition of the JRCALC Clinical Practice Guidelines, due in March 2016, will reflect the RCUK’s position. Hopefully it is accepted in full and used as a springboard to support a significant shift forward in paramedic ROSC care. Any unwelcome hesitation by JRCALC should be unlikely against a context of excellent quality and specific pre-hospital recommendations released as recently as 2015 from a seminal organisation such as RCUK.

References:

1. Cardiac Arrest Annual Report 2010/11 (2011), London Ambulance Service NHS Trust, http://www.google.co.uk/url?sa=t&rct=j&q=&esrc=s&source=web&cd=6&cad=rja&uact=8&ved=0ahUKEwjao_r1jIHLAhVBWSwKHbpFBLMQFghFMAU&url=http%3A%2F%2Fwww.londonambulance.nhs.uk%2Fabout_us%2Fidoc.ashx%3Fdocid%3Db77b0219-5446-4136-ac0a-f936af6e1989%26version%3D-1&usg=AFQjCNFYUUaIcqou6xMGfqEGwLhRxv9esQ
2. Cardiac Arrest Annual Report 2014/15, (2015), London Ambulance Service NHS Trust, http://www.google.co.uk/url?sa=t&rct=j&q=&esrc=s&source=web&cd=5&cad=rja&uact=8&ved=0ahUKEwjao_r1jIHLAhVBWSwKHbpFBLMQFghAMAQ&url=http%3A%2F%2Fwww.londonambulance.nhs.uk%2Fabout_us%2Fidoc.ashx%3Fdocid%3D2d51ac9a-bd44-4cc4-9443-946533911275%26version%3D-1&usg=AFQjCNFFjbebJmwJWu26nB1nqNnSALiNHw
3. Survivors 2015, South East Coast Ambulance Service NHS Foundation Trust, http://www.secamb.nhs.uk/about_us/our_successes-1.aspx
4. Team approach to resuscitation (2015), Resuscitation Today, http://www.google.co.uk/url?sa=t&rct=j&q=&esrc=s&source=web&cd=9&cad=rja&uact=8&ved=0ahUKEwjb1q2fj4HLAhVLhSwKHXQXBWoQFghVMAg&url=http%3A%2F%2Fwww.resustoday.com%2Fwp-content%2Fuploads%2F2015%2F07%2F34519_Resus_Today_Summer_2015_V3_WEB.pdf&usg=AFQjCNGTZHJOlZ02FRWuWYLTTArHFYBGmw&bvm=bv.114733917,d.bGg 5. Airways-2 trial (2015), University of Bristol, http://www.airways-2.bristol.ac.uk/
6. PARAMEDIC2 trial (2016), Warwick Medical School, http://www2.warwick.ac.uk/fac/med/research/hscience/ctu/trials/critical/paramedic2/
7. Treat cardiac arrest patients at the scene, says top doctor (2014), Independent, http://www.independent.co.uk/life-style/health-and-families/health-news/treat-heart-attack-patients-at-the-scene-says-top-doctor-9751659.html
8. Resuscitation Policy (2014), South Central Ambulance Service NHS Foundation Trust, http://www.google.co.uk/url?sa=t&rct=j&q=&esrc=s&source=web&cd=5&cad=rja&uact=8&ved=0ahUKEwjtz5b6lIHLAhXCuBQKHY7eDbwQFgg7MAQ&url=http%3A%2F%2Fwww.southcentralambulance.nhs.uk%2F_assets%2Fdocuments%2Fpolicies%2Fclinical%2Fcspp%25203%2520resuscitation%2520policy%2520v4%2520july%25202014.pdf&usg=AFQjCNFg_oaz1vEzB5B4Zpt7f4GBnH_ReA
9. Clinical Practice Guidelines (2013), Joint Royal Colleges Ambulance Liaison Committee, http://www.jrcalc.org.uk/guidelines/
10. Post-resuscitation care (2015), Resuscitation Council (UK), https://www.resus.org.uk/resuscitation-guidelines/post-resuscitation-care/
11. Prehosital resuscitation (2015), Resuscitation Council (UK), https://www.resus.org.uk/resuscitation-guidelines/prehospital-resuscitation/

College of Paramedics Conference 2016 in 16 tweets

On the 8th and 9th of March, the College of Paramedics (@ParamedicsUK) held their 2016 conference in York.

Around 140 attended; predominantly NHS paramedics but student paramedics, emergency medical technicians and one very keen person who is trying to get into the ambulance service was using the conference to build their CV!

The biggest strength of the conference was networking opportunities with colleagues from around the UK; some really great programmes are happening to improve patient care around the country and want to share their success. For example, I learnt about a dedicated cardiac arrest response service in Edinburgh achieving remarkable results and this will improve my knowledge and understanding despite working over 300 miles away.

Twitter featured very heavily throughout the conference, using the hashtag #ParaConference16 so below is a tweet to sum up each presentation…

Inaugural Mark Bloch Lecture Professor Andy Newton “Professor Andy Newton discussing the changing emphasis of the paramedic and the Career Framework of the COP” @AndyJonesCOP

Paramedics Perceptions of caring for people who Self Harm: An evolved grounded theory Nigel Rees (@NigRees1973) - Head of Research & Innovation, Welsh Ambulance Service NHS Trust “Ethically and morally we don’t feel supported by law in decision making for self harm patients” @Auntymelon

College of Paramedics AGM “AGM time for @ParamedicsUK. Now represent >30% of @The_HCPC registrants, has charitable status, PEEP report & prescribing” @medic914

Walking the Walk – it’s not enough Paul Gowens (@PaulGowens) - National Clinical Advisor, Scottish Government Health and Social Care Directorate “Leadership is situation dependent, understand your role don’t get situation precious!”

The benefits of end-tidal Co2 monitoring in non-cardiac arrest patients: A pre-hospital perspective Keiran Bellis (@KeiranMBellis), North West Ambulance Service “ETCO2 used to differentiate between cardiac/resp conditions enables better mgmt….incl hyperventilation/neuro/anaphylaxis” @JStreetUK

Mentally Healthy David Davis FcPara (@DavidDPara), NHS 111 Workforce National Clinical Lead, NHS England “Rate of mental illness in paramedics 3.3 times higher than general population” @ParaJon82

The clinical holding of children: Do Paramedics need professional guidance Chris Preston (@medic992), Advanced Paramedic Practitioner, North West Ambulance Service “Holding children for any procedure should only be done as a last resort” @ChrisCPritchard

Teaching new dogs old tricks: integrating advanced skills into a paramedic-led air ambulance unit John McKenzie (@MyOtherCarIsaTVR), HEMS Paramedic, Lincolnshire and Nottinghamshire Air Ambulance “Advanced analgesia in use by Paramedics on @LNAACT: Ketamine, Midaz and Flumazenil” @medic914

To PEEP or not to PEEP - That is the question Patrick Mitchell (, Director of National Programmes - Health Education England “More paramedics, higher entry qualifications, increased career progression and more options outside trad ambulance services. Thoughts from PEEP” @mcclg

Improving clinical outcomes and hitting targets - Are they mutually exclusive? Dr Dave Macklin - Executive Director of Operations - Yorkshire Ambulance Service “More than ever, an important role in paramedic practice is patient advocacy” @FloBach

Professional Discipline – Friend or Foe? Andrea James (@HealthRedLawyer), Partner, Shoosmiths LLP “Fitness to practice on the regional CPD agenda? ALL registrants need greater awareness” @WilBroughton

Prevention is better than cure - Do paramedics have a role in public health? Linda Hindle (@HindleLinda) - Lead AHP - Public Health England “Fire Police Ambulance are health assets that can contribute to public health but need consensus about moving forward” @TeesParamedic

Improving pre-hospital care of patients suffering adrenal crisis Karl Charlton, Research Paramedic, North East Ambulance Service “Even simple self-limiting illnesses can be fatal in those with adrenal insufficiency” @ChrisJ999

Partnership working and collaboration: Enhancing patient care in Northern Ireland Ciaran McKenna, Northern Ireland Paramedic “In Northern Ireland, 20,000 999 calls each year for older people who fall” @MLG1611

Identifying pre-hospital factors which influence outcome for major trauma patients in a regional network: an exploratory study Lee Thompson (@PHKiTPara), Senior Paramedic (Trauma), North East Ambulance Service “Average major trauma victim is 38 yr old man” @medicalexwalter

College of Paramedics Executive Questions and Answer Panel [On topic of College activity around paramedic retirement age] “How many paramedics reach retirement age? Studies show high mortality” @Richki55

Other activities at the conference were stalls by Penthrox, Zoll, Capita, Physiocontrol, Corpuls, Yorkshire Ambulance Service, MedicNow and Openhouse among many others plus a gala dinner with live music.

Details of next year’s conference are yet to be announced, but if you value your profession and have a passion for paramedic development, I can strongly recommend going along and getting involved.

Matt Green @MLG1611
March 2016

What's on your list?

Every career in pre-hospital care starts with a first day. Well; two first days. The first day of training, and the first day of placement where you put all the training to the test on real patients who actually depend on you.

Almost every course, from basic first aider to student paramedic and beyond, builds heavily on the DR<c>ABCDE model that any emergency can be competently handled by working through the list of Danger, Response, Catastrophic haemorrhage, Airway, Breathing. Circulation, Disability and Examination/exposure. Fortunately it’s a tried and tested formula that works and saves lives every day. 

But having the training and knowing the cornerstones of emergency medical care can only go far in making you a great practitioner. You also need experience, which unfortunately you can’t download as an eBook, gain from a friend or master in a simulation. You need to get out there and do it.

These realities mean that many practitioners start with two lists; the `exciting list` and the `nervous list` which they gradually and informally check off until they have experienced each thing at least once, and therefore know how they would do it better next time.

I am excited to…
…drive on blue lights to an emergency
…drive on blue lights to hospital, with a patient on board
…have an air ambulance arrive at a job
…deal with a fire
…force entry to a property
…press the magic button on a defibrillator


I am nervous about…
...doing chest compressions
…telling someone their relative has died
…looking after a very sick child a long way from hospital
…having an airway I am unable to manage
…being confident in identifying a myocardial infarction and acting on it
…driving a patient with major trauma passed several closer hospitals to access a major trauma centre

Neither list neatly fits into a `top 5/10/20` as both are built on dynamic doubts and passions which are much more complex and change based on the culture you work in, the level of your training and your innate personality. 

In a busy ambulance service, it often takes 2-3 years to see one example of everything, and the guarantee of emergency medicine is that next time you see the exact same situation, it may be completely different! 

* Are lists like these healthy?
* What is/was on your list? 
* What are the things on your list still to check off?

Matt Green @MLG1611
July 2016

Paramedics need degrees

“Time of death 1854 hours.” There. You said it. You ended someone’s life. You’re 21 years old, still living with your parents and barely an adult in many eyes but you’ve just welded one of the biggest emotional swords available. They are dead and it’s because you said so. 

You recently registered as a paramedic and completed a few preceptor shifts before going it alone. That was the first real test; the first time without a mentor to depend on and when you’re expected to take the lead and make every decision without error. As if to prove the point, the first job was a 34 year old male in cardiac arrest.

There he was, laid in the gym beside the treadmill still whirring away. It was looking bad from the start; despite good bystander CPR, there was asystole from the moment you put the pads on. Your ECA crewmate did some sterling CPR while you tried various interventions. A second crew arrived; a technician and an ECA you knew well as a student but were now clinically commanding to save this patient’s life. 

You were there 40 minutes; you really did try everything until the sweat beads poured from your bodies. Nothing worked and you pressed on until it was time to stop. You were a long way from hospital, so copping out and conveying there was not an option. “Give it 10 more minutes” you said, reluctant to let it end like this but knowing the literature afforded this patient almost no hope of survival.

The gym emptied save for two earnest police officers who’d arrived in grim anticipation of the outcome. You knelt back and glanced around, thanked everyone for the efforts and stopped. 

The formalities swallowed up the next few hours and you felt a conflicting pride that you did your duty, with a vague shaky feeling about what you’d done. You know while directly not your fault; something beyond you must have happened to make the patient die, yet you also know that his friends and family will always know he died at that time, at that place and in the conditions you bare responsibility for. Perhaps they will get to ask you about it at a coroner’s inquest.

When all was said and done, you know you did your best. Later on plenty of more experienced, more qualified paramedic colleagues reassured that you did well and your managers supported you.

The rest of the shift was less life and death; a grizzly child who needed assessing and referral to a GP who wanted lots of detailed information and based on your diagnosis decides they don’t need a follow up appointment today and can be seen in their regular surgery tomorrow. This felt a great outcome; other professionals value your assessment skills, the child’s family had minimal disruption and didn’t need to go to the paediatric emergency department miles away, there is less demand on scarce emergency resources which is good news for the NHS and it’s an overall great use of your professional autonomy.  

However, you’re plagued by lucid thoughts; what if you made a mistake; what if you missed photophobia, bulging fontanelles and a non-blanching rash. You absolutely know you didn’t but it plays on your mind…what if you did? 

The final patient was being transferred between hospitals; despite being fairly young, the next day her foot was being amputated after a string of complications meant an ulcer never healed and her necrosed foot was unsalvageable. She had fluids running and on 6 different antibiotics and
painkillers; you’d been trusted with diamorphine to give PRN during the transfer by the dispatching hospital who had no escort to send with the patient. The patient wanted to talk and mourn her foot. She liked having two feet that worked; she liked the freedom, the independence and the spontaneity they afforded. She is stoic about how she will cope but is coming to terms with how it will affect her life, her perception of herself and she openly says she thinks she will become depressed or have post-traumatic stress disorder or both. She casually asks you about the differences between the two and what you recommend to help her cope with it. “You do know, don’t you?” she says while you tried to reflect confidence and competence beyond your years “you will have studied this” she follows up. 

The shift ended; it was ok. It was fun, it was challenging. It was what you thought being a paramedic was all about when you applied. 

On the way home you reflect that had you studied medicine you’d still be at university, looking forward to years of supported learning and structured mentorship. In nursing you’d need to build up many years of post-registration nursing study and experience before autonomously practicing like you’ve done today.  

But as a paramedic, the autonomy was there on the first day. Expected to give high doses of morphine, diazepam and amiodarone here, delivering a baby there and actively trying to discharge as many patients as possible on scene. It feels like it only takes one person to disagree with one decision once and the HCPC Fitness to Practice process could bare down on you and ultimately strike you off.

That’s frightening.

Looking forward, one day you’d like to focus on one area of practice. Specialist Paramedic in Critical Care is an option. Perhaps you’ll become a Resuscitation Officer in hospital or a researcher at a university. Maybe you’ll sail the seven seas as a paramedic on a cruise ship or move to a third world country to develop an ambulance service there. Perhaps when you’re ready to put down some roots, working in a GP surgery might be a great work/life balance in a beautiful part of the country. So, so much feels open to you – and it all starts as a registered paramedic. 

Just one newly qualified paramedic in just one day assesses, manages, discharges and refers patients with significant clinical risk. They deal with polypharmacy, mental health, life changing moments and wrestle their own aspirations to enjoy a fulfilling career. There are hundreds of new paramedics seeing tens of thousands of patients making millions of risky decisions every year.

It is clear that all paramedics needs to be highly qualified and competent individuals to give them the skills and knowledge to make the most of their experience in practice. Able paramedics give the public confidence and strengthen our professional case for more drugs and techniques to be added to our scope of practice, to provide an even better service to our patients and be a greater asset to the health service. 

It is simply not appropriate nor plausible for future paramedics to practice at this level and beyond with anything less than a bachelor’s degree in paramedic science/practice in addition to the experience and mentorship afforded them by well-designed placements with good ambulance clinicians within trusts. This is the right basis for a career of post-registration study and continuing professional development. 

The HCPC are currently proposing to maintain a Certificate in Higher Education as the minimum education standard for registering as a paramedic.

If you agree or disagree with this blog post and the standards of education for paramedics to become registered, tell the HCPC’s consultation at http://www.hcpc-uk.org/aboutus/consultations/index.asp?id=220

Matt Green @MLG1611
September 2016

Mealbreaks

Working as ambulance personnel has all the hallmarks of an exhausting job; long shifts day and night, repetitive heavy lifting and prolonged concentration to ensure a safe, professional and dignified approach to every patient and colleague. 

Wherever you work for the emergency services, from the moment you consider applying, it’s obvious the work’s going to be physically, mentally and emotionally challenging as well as unpredictable. Clinicians often relish the excitement and reward this brings.

But no person can work indefinitely to a high standard, which is why breaks are so important and humane. 

During breaks, which are generally unpaid, ambulance staff might be eating what may be their only warm food and drink of the day to stave off hunger and dehydration which impairs judgement, napping to ensure they can later safely drive a 4.5ton ambulance at 85 miles an hour to a dying patient or talking with colleagues about recent football results to block out the seething frustration at the obstructive bystander who swore at them earlier. 

Whatever ambulance crew do on their break, it’s often things that contribute to good mental and physical health. Often. But not always; there are frequently emails to be answered, vehicles to be restocked and important conversations with managers and administrative staff required which eat into breaks but are undertaken out of necessity and the goodness of staffs’ heart. Doing these tasks at the start or end of a 12 hour shift is impractical as some issues can only be dealt with inside office hours. 

Nonetheless, the provision of breaks are controversial and logistically difficult. It is common sense that tired ambulance staff can dangerously underperform, experience health problems and service-wide morale suffers affecting strategic performance. Many of the meal break points have been explored in depth by employers, unions and professional bodies and there are no simple answers.
What times should breaks be? Where should breaks be taken and what facilities should be available? What is the knock-on effect of taking a break on the availability of emergency medical care in that area? 

Crucially and extremely emotively, is there ever an emergency so dire that ambulance staff should be expected to attend during a break (when they are arguably `not at work`) or does respect for `downtime` need to be absolute for a break to be worthwhile? It is almost impossible to reconcile a seasoned professional’s benchmark for this with the opinion of wider society. It is even harder for ambulance services to produce a meal break policy which is applicable in every circumstance, every day of the year given the number of mundane and life-and-death variables involved.

In extremis, no ambulance clinician would ever hope to finish their KitKat before attending a child with meningitis and would give their all if dispatched. However, if the next day there’s
an interrupted meal break to a man with chest pain, the day after disruption for a breathless asthmatic and a disturbed meal break for unresponsive, intoxicated, 20 year old outside a night club on the following shift, the cumulative toll mounts up and the exceptional interruption to the break legislated for in the policy becomes a routine response to another `red call`. 

Commonly, compensation structures are in place to financially offset a ruined meal break; this is a valued but materialistic sticking plaster over an issue that really can leave colleagues vulnerable to debilitating tiredness which can eventually contribute to debilitating mental and physical illness.

Unless demand for ambulances is reduced, or resource levels increase enormously, there are few easy solutions to ensure all ambulance crews are adequately rested during their 8-12 hour shift, which may even then unavoidably overrun by several hours. Managers and control room staff will always wrestle with the daily respite needs of crews balanced with the insatiable operational appetite for vehicles to attend emergencies within reasonable and clinically relevant timeframes.

Matt Green @MLG1611
November 2015

Airway management in end of life care

The case

This case study looks at some of the airway complications in end of life care and clinical decision making in the context of a dying person. Also discussed are examples of techniques and medications a pre-hospital clinician might use to manage symptoms.

You’re called to a 66 year old female in a collapsed state. You find the patient laid in bed and complete a primary survey. 

D – none

R – aVpu

A – snoring, dry tongue with thick mucus secretions, very slack tone in facial and airway muscles

B – RR 28, shallow and irregular. SpO2 93% on air. Audible stridor with occasional cough

C – HR 51, strong and regular radial pulse. BP 105/59

D – GCS 10 (E3V2M5). PEARLA 3mm. Some facial grimace. BSL 6.4

E – Temperature 36.6. Cachexic, with a functioning urinary catheter

Management

Your instincts are to resuscitate this patient, initially with airway management including tracheal suctioning, positioning, adjuncts, and oxygen before facilitating rapid transfer to hospital. However, you sense this patient has a complex medical history; there is a hoist near the bed and grab rails on the walls and you can see a NHS-branded file full of notes too.

Speaking with the patient’s family you learn that the patient has incurable brain cancer. She was diagnosed 4 years ago and has had repeated hospital admissions for various issues including aspiration pneumonia, seizures and headaches. Four weeks ago she was discharged for palliative care at home and it was agreed that further hospital admission was inappropriate if avoidable. When she was discharged, the patient was conscious and had capacity. The family show you a valid DNACPR and a comprehensive Advance Directive where the patient states she simply wishes to be made comfortable and to die at home. Her husband has evidence that he has Power of Attorney for Health and Welfare, and continues to support his wife’s Advance Directive. There is also an abundance of paperwork from the local palliative care team, hospice and district nursing service. The ambulance control room have a record from the patient’s GP that corroborates all the key facts. The patient has carers twice daily who help with personal care, give a thickened puree diet and administer oromorph and sodium valporate. Other medications such as statins and antihypertensives have been recently stopped by the GP as their long-term benefits are no longer relevant.

The family explain that they called 999 when the patient’s breathing started to become noisy and she was less responsive. They feel a little guilty for calling an ambulance but you can tell their genuine concern and realise they simply lost their nerve a little during this difficult stage.

Overall, you determine the patient is probably in the last days of life and that transfer to hospital would not be appropriate, potentially distressing and unlikely to positively alter the outcome.

You also consider that typical emergency aggressive airway management aims to stabilise the patient and be part of a package of resuscitation care to achieve definitive management and promote recovery. As this patient’s rapidly declining health makes recovery and short-term survival impossible, priorities in end of life care airway management focus on reducing discomfort and lessening symptoms without resorting to futile painful and invasive procedures with no long-term benefit.

You telephone the palliative care team for advice. They suggest to make the patient comfortable and if possible improve her airway symptoms. They are able to visit the patient later on, but it will be at least 3-4 hours until they can get there. The palliative care team tell you there is a box of prescribed `just in case` medication and equipment in a box at the bottom of the patient’s wardrobe. A chart for indications and recording administration is in there too.

You start by helping sit the patient up a little – the patient’s family help you slide her up the bed and use a few more pillows until the patient is semi-recumbent. Immediately, her snoring becomes less pronounced and airway patency improves, however the improved airflow increases the volume of the rattle caused by her secretions.

You use damp gauze to gently remove some of the thickened secretions around the patient’s lips but doubtful that suction would be effective without being excessively invasive and using a large catheter on high power for a prolonged period.

The patient’s family find the `just in case` box. Inside you find a range of vials as well as a range of syringes, needles and devices which look like sponges on sticks, which you realise are for safely giving the patient small amounts of water to wet their mouth without risking significant aspiration.

The documentation inside the box relating to stat doses (as opposed to syringe driver doses) states:

You decide to wet the patient’s mouth using the sponges, which loosens some secretions and makes them easier to remove with gauze. You also decide to administer a dose of Glycopyrronium.

Chemically related to atropine, Glycopyrronium prevents muscarinic receptors’ stimulation by acetylcholine, which ordinarily is a normal process of the parasympathetic nervous system to release saliva. Reducing saliva reduces further secretion production and therefore relieves turbulent airway airflow.

After administering the medication, you consider undertaking further monitoring including blood pressure, a 12-lead ECG and end tidal carbon dioxide. However, you decide not to reattach the machine as the patient’s prognosis means her observations are likely to be deranged, and you would be unlikely to change your management as a result of any findings. Even if there was a life-threatening abnormality, treating it would probably not be in the patient’s best interests if it was not causing distress.

In order to know whether these interventions have been effective, you decide to remain with the patient for 30 minutes. While waiting you speak with the patient’s family and put their mind at rest about a range of issues. They feel much more prepared for the patient’s final days and confident they will be able to look after the patient until the palliative care team arrive later on.

Before leaving scene you review the patient. 

A – much less noisy with fewer secretions

B – RR 22, still shallow

C – no change

D – less distressed and responds to voice

E – positioned more comfortably

Further reading

1. Joint Royal Colleges Ambulance Liaison Committee and Association of Ambulance Chief Executives (2016) UK Ambulance Services Clinical Practice Guidelines 2016. Bridgwater: Class Professional Publishing.
2. Electronic Medicine Compendium (2016) Glycopyrrolate Injection U.S.P. 200 micrograms/ml, 1ml & 3ml.
3. National Institute for Health and Care Excellence (2015) Care of dying adults in the last days of life.

Matt Green @MLG1611

November 2016

Pre-hospital haemorrhage control `then and now`

When I was a fresh IHCD Trainee Ambulance Technician, an old hand of 44 years’ service remarked that the public always expect an ambulance person to have a bandage to hand. He reasoned not having other equipment would go unnoticed by the general public, but a bandage should always be within arms’ reach as part of good patient care, and to ward off complaints.

In those days, haemorrhage control was limited to simple dressings whose design had been unchanged for decades and raising a wound before popping the patient to the nearest Emergency Department. In some cases, copious IV fluids were given before leaving scene `to make up for what the patient had lost` and rapid infusions continued on route to hospital. In an era before widespread reconfiguration of emergency departments and hospital downgrades, a receiving facility was rarely more than a few short minutes’ drive away, where it was blindly assumed expert care was immediately available from all clinical grades. 

It was the year 2007.

Since then, haemorrhage control techniques used in pre-hospital medicine have swelled. The dogma of opening the airway before controlling massive bleeding has crumbled, and there is now a choice of traditional bandage or specialised pressure dressing or arterial tourniquet or haemostatic gauze or tranexamic acid which can be mixed and matched to the specific situation. There is intraosseous access for carefully titrated infusion of saline where IV access is impossible or insufficient, and the use of pre-hospital blood transfusion is expanding and being tested by the RePHILL trial (Birmingham.ac.uk/RePHILL) to ensure efficacy. Specialist paramedics offer sutures, steri-strips, glue or staples for wound care and novel solutions such as the iTCLAMP (innovativetraumacare.com) and REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) are been reported to conference audiences who lap up the promise of saving more lives. 

The flagship network of consultant-led major trauma centres are available nationwide 24 hours a day, with an integral role for damage-control surgery and secondary transfer from local trauma units where indicated. For patients with haemorrhagic shock in cardiac arrest, there are now standardised Resuscitation Council UK traumatic cardiac arrest guidelines and a more clearly defined role for resuscitative thoracotomy than has been seen previously. 

The net effect is that we certainly save more people than we used to; there are even suggestions that making haemostatic gauze and arterial tourniquets available to untrained members of the public might help reduce life-threatening haemorrhage in the first few minutes before trained personnel arrive, following a similar model as public access defibrillation. An idea which probably needs to be examined much more closely before any rollout. 

While the future is bright for saving those who are bleeding to death, it should be remembered that in accessing trauma networks, ambulance clinicians are managing traumatised people for up to 60 minutes’ drive time (plus on-scene time); longer distances and durations than ever demanded before and unanticipated in many colleagues’ initial training. As such, there is a need for continued profession-wide unity to ensure pre-hospital practitioners have the education, medications, equipment and autonomy to make this a reality and to avoid patients suffering in ambulances miles from definitive care with ambulance staff unable to meet the patient’s clinical needs.

Matt Green @MLG1611
August 2016

Originally published by Critical Care in Pre-hospital Practice @CCinPP

Burning bridges; things your patient might not want to hear

Ambulance clinicians are generally unable to revisit patients to review their progress.

We reflect that GPs can arrange another appointment, or consider district nurses’ assurance when they will next attend a patient’s home.

Emergency Department staff rely on seeing a patient over several hours to develop a sensible management plan, and for admitted patients there is relative certainty they will remain in a safe place until treatment, delivered by colleagues they know and trust, has concluded. Where there is an ongoing issue after inpatient care, a service user can easily be booked in for a clinic appointment.

In contrast, the ambulance services have a propensity to assess, diagnose, treat and refer within just one episode. There is little chance a service user will see the same ambulance clinician again, even if they call appropriately recall 999, and so lack an opportunity to develop a professional rapport based on multiple contacts.

While the ability to see a patient repeatedly and predictably confers significant advantages and might be a very pleasant way to practice, there too are potential advantages for the ambulance clinician in the implicit understanding they are unlikely to see that patient again.

Where circumstances are medically or socially complex, or potentially distressing but unexplored themes such as end of life care or psychosomatic symptoms are emerging, a non-ambulance practitioner expecting a medium or long-term partnership with the patient, family and carers might need extreme tact and diplomacy to maintain good communication channels. It is potentially difficult to talk about a patient’s expected death if you know you’re likely to see them many more times before it happens. It is hard to know if frank conversations will be taken badly, hurt feelings and erode the trust you have developed, maybe over decades of friendship with the patient’s family.

Ambulance professionals, as autonomous clinicians with substantial executive power within a context of very discrete episodes of patient contact, are in a valuable position to initiate and navigate difficult conversations, and do something useful with the results.

-“I don’t think you are coping” to the exhausted husband of someone living with dementia, but too proud to ask for help

-“Sometimes the mind causes genuinely distressing symptoms that we can’t easily explain. Could anything within the family be upsetting them?” to the quarrelling parents of an adolescent having inconsistent symptoms.

-“If you carry on living like this you’re at serious risk of dying” to the drug user whose lifestyle has spiralled out of control

-“It looks like someone did this to you; would you like to talk to the someone who can help?” to the patient with the bruised face after what may be a domestic assault

-“When your heart failure gets worse and treatment isn’t allowing you to enjoy life any more, have you thought about where you would want to be cared for and ultimately die?” to the frail patient with bilateral rales and a poor quality of life

-“What will you be happy with in a year?” where a patient’s family need help imagining what bereavement might be like

A person might feel able to say things to the kindly but fairly anonymous ambulance crew they have felt unable to say to close family members who want to talk about “hope” or “battling” disease. If their specialist has spent years talking about cures, interventions and “next steps”, a patient might worry about hurting their doctor’s feelings to ask whether more chemotherapy is really going to be worth it to prolong their life a little more.

Sometimes a patient will see your intuitive and sensitive questions and observations as a light being thrown upon their crippling darkness and embrace your help. Other times the conversation might be fraught and confront service users’ painful inner feelings as waves of emotional turmoil are offloaded. Rarely, the patient’s trust in you might be irreparably damaged and they may disengage from further discussion, but they will still have cordial feelings towards their day-to-day health professionals who have not confronted them in the same way. Perhaps they will later reopen the conversation with other professionals, but on their own terms.

Saying things people don’t want to hear can sometimes be the right thing to do and be hugely productive to ongoing care, but someone needs to say it to find out.

Without nastiness, prejudice or unprofessional behaviour, there are times and places ambulance professionals have the almost unique opportunity to risk `burning bridges` on patient’s own territory. With consent, you can act on your findings or pass them onto someone else who can help. The patient’s reassurance they are unlikely to ever meet you again keeps a reassuring exit point to agonising conversation and objective discussion.

In a year’s time and when the dust has settled, perhaps they will be thankful you said it.

Matt Green, @MLG1611
February 2017